GW1-2022-06486_Well Construction - GW1_20220706

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RmDEium WELL CONSTRUCTION RECORD
North;Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTrFICATION#
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1,WELL CONTRACTOR g< WATER ZONES(de th
TONY R DAVIS Top Botto Top Bottom
Weli Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Well Contractor Company Name Thickness!
1481 LARRY DAVIS ROAD 7. CASING: Depth Diameter Weight Material
Street Address Top Bottor..4ff k: 24 1.5 Cement
LAWNDALE NC 28090 `
Top Bottom Ft
City or Town State Zip Code Top__ Bottom Ft
z 7t?4 276-3434
Area code Phone number 3. GROUT: Depth Material Method
2.WELL INFORMATION: Top 0 Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT# Top Bottom Ft
07- ER ASSOCIATED PERM IT#(tfapplicable) Tog Eottom Ft.
SITE WELL ID#(if appricable) 9, SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check pplicable Box): Residential Water Supply p Top Bottom Ft: in, in.
DATE DRILLED r Top Bottom Ft in. in.
.24e1 Top Bottom Ft in. M.
TIME COMPLETED AM❑,''`PM
4,WELL LOCATION: 10.SAND/GRAVEL PACK:
LAI
Depth �+� -Size Material
CITY: tcouNTY A Top­�ottom_-!_ot. 78--M Gravel
G S ,/ Top Bottom Ft.
(Street Name,Numbers,Communky,Subdivision,Lot No.,Perrzi,Zip Code) �! Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (chem appropriate box)
oSlope dValley *-e t1Ridge ❑Other 11. DRILLING LOG
'Top Bottom Formation Description
LATITUD -24 DMS OR 3X.XXXXXXXXX DD /
LONGITUDE • ^ IDMS OR 7x.XXXX)CXXXX DO
Latitude/longitude source: 39105 Cropographic map / --
(location of well must be shown on a USGS topo map andattached to
this form if not using GFS)
5.WELL 0 NER ��
0% Uri:+
. t
er Name
treat ddress, ..���..�
City or Town Stats Zip Code /
Area code Phone number
12, REMARKS:
C WELL DETAILS:
a. TOTAL DEPTH:_ _ - `�
b. DOES WELL REPLACE EXISTING WELL? YES[3NOL+Y'" I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 114
c. WATER LEVEL Below Tap of Casing: ACCORDANCE WITH 15A NCA•..2C,WELL CONSTRUCTION
(Use`+'if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
.� t PROVIDED TO THE WELL OWNER.
d. TOP OF CASING is�—J--- FT.Above Land Surface` P01
`Top of,casing terminated atfor below land surface may require �� ,,a variance In a�ordance with 15A iVCA.0 2C.0118• S NATURE TtFtED ELL C ATE
e, YIELD(gpm): METHOD OF TEST TONY R DAVIS f
f. DISINFECTION:Type mount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of Completion to: Division of Water Quality - Information Processing, Form OW-1a
1617 Mail Service Center, Raleigh, NC 27699.161,Phone:[phone] Rev.2/09